Apa yang Harus Diubah dari Pola Pikir Dokter dan Mahasiswa FK Indonesia?

 

Belajar dari Prof. DR. dr. H. Faried Anfasa Moeloek, SpOG

Pada beberapa waktu lalu, saya diberikan kesempatan dari Sekolah Kepemimpinan Fakultas Kedokteran di mana saya berada untuk belajar lebih lagi tentang isu kesehatan Indonesia sekarang ini. Pada kesempatan kali ini, kami belajar langsung dengan mantan Kementerian Kesehatan Republik Indonesia, Prof. DR. dr. H. Faried Anfasa Moeloek, SpOG pada periode 1998-1999.

Saya dan teman-teman saya belajar banyak hal pada kesempatan itu, termasuk kesalahan-kesalahan maupun hal-hal yang kerap dilewati oleh tenaga kesehatan dan bahkan mahasiswa Fakultas Kedokteran di Indonesia. Selama ini, kami terlalu distigmakan dengan penyakit – obat, etiologi – tata laksana, yang telah diajarkan di FK kami. Akan tetapi, kita melewatkan untuk meninjau lebih lagi akar dari masalah kesehatan tersebut. Dengan meninjau akar masalah dan menggunakan prinsip menyelesaikan 1000 masalah dengan 3-5 solusi, kami dapat melihat masalah kesehatan dengan lebih holistik dan dapat menyelesaikan masalah kesehatan tersebut dengan lebih baik lagi.

Sebagai contoh, Prof. Farid Moeloek memberikan kita 2 contoh isu kesehatan di Indonesia yang sampai sekarang masih sulit ditanggulangi. Pertama, tuberkulosis (TBC). TBC merupakan menyakit yang disebabkan oleh bakteri Mycobacterium tuberculosis yang tidak hanya dapat menginfeksi paru-paru manusia dan menyebabkan TBC paru-paru, tetapi juga organ-organ lainnya, seperti … Ketika kami ditanya, apa yang dapat kami lakukan untuk mengobati masalah tersebut. Jujur, hal yang pertama kali terlintas dalam benak kami adalah untuk memberi pasien tersebut obat … Akan tetapi, hal tersebut SALAH BESAR. Kami hanya mengobati yang sakit, menanggulangi masalah secara akut. Bagaimana secara kronisnya? Masih akan banyak pasien datang ke dokter Indonesia dengan masalah TBC. Di sini kami ditegunkan kembali, obat TBC merupakan “Kemakmuran Rakyat”, pendekatan multidisiplin harus dilaksanakan untuk menanggulangi masalah ini, termasuk bagian pengolah lingkungan untuk menjadikan Indonesia ini tempat yang lebih ramah lingkungan, bebas dari TBC.

Bagaimana dengan angka kematian ibu dan bayi yang masih tinggi di Indonesia? Apa yang sebenarnya salah dari sistem di Indonesia? Apakah karena pelayanan antenatal yang sering diabaikan si Ibu? Ternyata, pelayanan antenatal tidak sesignifikan itu untuk menurunkan mortalitas ibu dan bayi. Kami berpikir dan berpikir. Lalu kami diingatkan kembali dengan status pendidikan yang masih rendah di kaum hawa Indonesia. Memang, perempuan yang berpendidikan itu dapat lebih berpikir, bahwa 4 “toos – too young, too many, too frequent, too old” merupakan faktor-faktor yang cukup berkontribusi tinggi dalam mortalitas ibu dan anak. Ditambah lagi dengan nutrisi yang kurang dikonsumsi oleh Ibu karena tingkat ekonomi yang tidak sepadan dengan pengeluaran keluarganya (terlalu banyak mulut untuk diberikan makanan).

Dokter-dokter di Indonesia seharusnya memiliki pemikiran yang holistik seperti itu juga sehingga pembangunan negara ini dapat terlaksanakan dengan lancar dan efektif. Sementara itu, mahasiswa-mahasiswa FK di Indonesia juga sudah sepantasnya belajar berpikir secara holistik seperti itu juga karena seperti yang kita tahu, masa depan bangsa ada di tangan kaum-kaum muda.

Demikian pikiran hasil inspirasi saya setelah berbincang-bincang dengan beliau. Saya berterima kasih kepada para pembaca yang telah meluangkan waktunya untuk membaca sepatah kata dari saya. Saya mohon maaf jika ada kesalahan pada konten maupun kata-kata.

#UntukIndonesiayangLebihBaik

Empathy vs Sympathy: Two Cliffs Connected with A Bridge Filled with Doctors

I have encountered the word “empathy” a lot since I first got into a medical school. First of all, empathy is an understanding process of other people’s subjective experiences by vicariously sharing those experiences but still keep an identity as an observant. (1) “Doctors should be able to set a clear border between empathy and sympathy. Increasing the quality of health care by empathizing patients, not sympathizing them,” is the sentence that I clearly remember is repeated all over again by my doctors. This makes me learn, think, and contemplate myself, I should be a good doctor who can empathize her patients, too! It has almost been 1.5 year since those moments, and I begin to reflect again, “have I been improving? Am I on the right track to be more empathizing rather than sympathizing?”

There are a lot of chances in which my empathy is tested since I got into this medical school. I recently participated in a charity event, in which I gave an education for mothers in rural area about the importance of having early detection of visual acetic acid cervical inspection and how to detect breast abnormal tumor mass. I was really happy that the mothers actively participated in the group discussions and gave several questions to deepen their knowledges towards the two most prevalent cancers in women. However, one of the mother, wanted to meet my friend and I after the discussion privately. Therefore, we met shortly after the group was disbanded.

The mother began to tell us her chief complaint and the history of her sexual health, starting from the fact that he married in such an early age, lost her husband ten years ago, having irregular menstrual cycle, and history of pap smear. I think she wanted to ask more about her sexual health status as we indeed put that having married at an early age and early menopause increase the risk of having cervical and breast cancer. She was indeed worried about that fact and wanted to ask us what she should do to prevent those from happening. Nevertheless, as medical students who have not gone to reproduction module yet (we only had a workshop about IVA and breast cancer), we admitted that we were not clear about her concern and offered her to tell her complaints to the doctor in charge the following week (when the inspection was conducted). The mother agreed and she went to the doctor on the day of the charity event.

It was such an unforgettable experience since I was actually quite sad by the fact that I was not able to answer that mother’s questions properly for I had not learnt and was not clear about it. Nonetheless, hearing her long complaint about her sexual health made me once again think that I still can be a good listener and empathize her albeit I cannot give her any solutions. Consequently, I decided to give my best efforts to everything that I can do at that moment; which was to listen to all my heart and encourage the mother not to lose hope but to seek for doctor’s helps. Furthermore, I was also encouraged by the fact that we should train ourselves about clinical empathy so that we would not have any problems in expressing empathy when we had graduated from medical school.

I imagined myself on her shoes, living life and taking care of two young children alone. Understanding that she was the pillar of the house, I fully understood that she needed to maintain her health well to be able to take care of her children’s health. Therefore, I would take the same decision as her, to have her health checked in that occasion. Nonetheless, what I did in that occasion was just to empathize her, tried to reach and understand her feeling. I set a clear border of not to share her suffering in order to ease her burdens and stopping myself in involving my personal feelings to her stories that can hinder my professionalism and identity as a medical student and aspiring doctor. Nevertheless, I tried to help her by encouraging her in talking to doctor’s and also offered to be a mediator for her to reach the doctor on the following week.

Thus, I think I have improved from the first time I got into the medical school since I also had a similar event when I was in the first year of medical school. I participated in a charity event with my batch, where I took the position of facilitator for families where the event was held. I went to my assigned families and there was a grandmother who lived alone with her daughter-in-law and granddaughter. In that occasion, I was supposed to explain the flow of the charity event. Nonetheless, the grandmother proceeded to cry and tell me stories about her tough lives since her son had gone. Things had been really hard for her since she had to work even though she was already 70 years old to support the family. At that moment, I was really touched by her stories and sad, so I accompanied her and also cried with her.

It was my first experience participating in a charity event. In as much as the fact that it was conducted in the first term of school, my knowledge regarding doctor’s empathy was not deep enough. In this case, I had clearly failed in expressing my empathy towards the grandmother. I involved my feelings to understand the patients’ feelings, pain, and suffering better, rather than knowing the patient better by showing empathy to the patient. (2) Now, I understand that as a physician, I should put myself on patient’s shoes as if I were them, knowing and maintaining our distance but try to reach them. In contrast with sympathy, which causes merging identities of the physicians by involving themselves to feel the same to their sufferings as if I were the sufferer. (3) Nonetheless, I acknowledged my fault and was willing to improve. Therefore, I am really happy to see my improvement in the last charity event, involving the mother from IVA seminar.

All in all, I am proud and eager to continue or even improve my empathy towards people around me so that I can be a better doctor by the time I finish studying in medical school. If I am faced with similar condition in which my empathy is tested, I will firmly hold my principle as a doctor, setting a clear border between empathy and sympathy, and choose to treat the patient with empathy in order to give better quality of health services, rather than involving my personal feelings which is done in sympathy.

 

References:

  1. Ionnidous F, Konstantikaki V. Empathy and emotional intelligence: what is it really about? International Journal of Caring Sciences. 2008;1(3):118-23.
  2. Lamothe M, Boujut E, Zenasni F, et al. To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice. BMC Family Practice. 2014;15:15.
  3. Thirioux B, Birault F, Jaafari N. Empathy is a protective factor of burnout in physicians: new neuro-phenomenological hypotheses regarding empathy and sympathy in care relationship. Fornt Psychol. 2016;7: 763.

Edukasi Pasien demi Kemajuan Bangsa

“Lagipula pasien juga tidak mengerti, waktu mepet, jelasin seperlunya aja deh!” Apakah ini hal yang patut dilakukan seorang dokter?

Permasalahan kekurangjelasan dokter dalam mengedukasi pasien sudah sering menjadi momok dalam kehidupan masyarakat Indonesia. Akan tetapi, perlu diketahui bahwa kekurangjelasan dokter dalam mengedukasi pasien sangatlah berdampak bagi kehidupan rakyat Indonesia sebagai pasien dari dokter Indonesia. Mulai dari ketidakpercayaan pasien terhadap dokter, pelayanan kurang memuaskan untuk pasien, dan pengobatan tidak berjalan efektif. Hal ini juga dapat berdampak secara luas hingga memengaruhi cara berpikir rakyat Indonesia yang cenderung menyerahkan semua masalah kesehatan kepada dokter. Padahal, seharusnya pasien lebih proaktif lagi dalam memutuskan pengobatan yang terbaik untuknya.

Banyak faktor yang tentunya membelakangi kekurangjelasan dokter dalam mengedukasi pasien, contohnya tingkat edukasi pasien dan keterbatasan waktu dokter untuk mengedukasi. Dokter memiliki cara berhubungan berbeda dengan setiap pasiennya bergantung dengan perilaku pasien terhadap penyakitnya. Ada pasien yang menyerahkan semua kehendak sepenuhnya dengan dokternya sehingga dokter tersebut menegakkan sistem paternalistik; ada pula yang sebaliknya. Oleh karena pendidikan masyarakat di Indonesia belum cukup tinggi, masyarakat Indonesia cenderung mengikuti semua kata dokternya. Hal ini tentunya membuat sebagian dokter terbiasa dengan menerangkan pasien seperlunya saja. Alhasil, pasien akan bergantung kepada dokter 100%. Ini tentunya tidak dapat dibiarkan. Meskipun pasien mungkin percaya dan menyerahkan keputusan terbaik kepada dokter, pasien harus tetap lebih dilibatkan dalam penanganan masalah kesehatannya.

Sudah banyak peraturan yang menitik tebalkan kewajiban dokter untuk mengedukasikan pasien dengan jelas. Hal ini dapat dilihat dari UU Nomor 29 Tahun 2004 tentang Praktik Kedokteran Pasal 52a yang mengatakan bahwa “pasien mempunyai hak mendapatkan penjelasan secara lengkap tentang tindakan medis.” Selain itu, Konsil Kedokteran Indonesia (KKI) juga menunjukkan di Peraturan KKI Nomor 4 Tahun 2011 Pasal 3 ayat (2h) bahwa “pelanggaran disiplin profesional Dokter dan Dokter Gigi sebagaimana dimaksud: tidak memberikan penjelasan yang jujur, etis, dan memadai (adequate information) kepada pasien atau keluarganya dalam melakukan Praktik Kedokteran.”

Di Inggris, sistem seperti “personalized asthma action plan” telah ditetapkan untuk menangani masalah darurat pada penderita asma. Program ini melibatkan pasien itu sendiri untuk menulis rekap tentang penyakitnya hingga penanganan bila terjadi kasus darurat pada pasien tersebut; tentunya dengan pengawasan dokter. Program ini tentunya memberikan wawasan kepada pasien dan orang di sekitarnya bagaimana cara bertindak bila kondisi darurat terjadi.

Mungkin informasi seperti penanganan personal pada kondisi darurat telah dijelaskan oleh dokter. Akan tetapi, informasi lisan tersebut berarti hanya pasien tersebut yang mengetahui penanganan tersebut. Sementara itu, kita mengerti bahwa saat kondisi darurat, orang di sekitar penderita tersebutlah yang memiliki peran penting dalam pertolongan pertama penderita. Dengan menyertakan informasi tertulis, penderita tentunya dapat mengantisipasi terjadinya keadaan darurat dengan memperbanyak copies dari informasi tersebut kepada orang di sekitarnya. Terlebih dari alasan tersebut, program seperti ini dapat menjadi pemicu bagi pasien untuk lebih proaktif lagi dalam mengetahui secara jelas penyakitnya.

Selain itu, kekurangjelasan dokter dalam mengedukasi pasien juga disebabkan dengan keterbatasan waktu yang dokter miliki untuk melayani pasien. Memang mungkin rasio ketersediaan dokter dengan jumlah penduduk Indonesia cukup timpang; yaitu sebanyak satu dokter untuk melayani setiap 5.000 orang penduduk Indonesia. Akan tetapi, hal ini tidak bisa membenarkan perilaku dokter yang mengurangi pelayanan edukasi pasien.

Ada banyak cara untuk menanggulangi masalah tersebut. Contohnya adalah dengan mengalokasi waktu antar-pasien karena setiap pasien tentunya memiliki kebutuhan dan alokasi waktu yang berbeda-beda. Jika memang tidak ada waktu untuk menjelaskan pada saat itu, dokter dapat menggunakan hari di mana ia tidak praktek untuk membuat appointment kembali kepada pasien yang memerlukan perhatian lebih.

Menanamkan Pendidikan Moralitas Dokter Sejak Dini

Sudah banyak kasus di Indonesia seputar menuntut dokter-dokter yang tidak bertindak sesuai dengan seharusnya. “Padahal yang terpenting dari sebuah profesi itu adalah trust,” tegas Prof. dr. Menaldi Rasmin, SpP(K), mantan ketua Konsil Kedokteran Indonesia (KKI) periode 2009-2014. Akibatnya, hubungan dokter dan pasien yang seharusnya terikat dalam kata ”trust” kini telah diragukan lagi. Tentu saja, banyak dokter lainnya yang menjadi korban dari ketidakpercayaan publik terhadap dokter Indonesia karena ulah senonoh beberapa dokter. Oleh sebab itu, perubahan harus segera dilaksanakan.

Mari kita kembali ke akar masalah. Sudah seharusya dokter memiliki karakter yang seperti seorang dokter pula. Dokter harus berprofesional dan dapat dipercaya sehingga pasien juga merasa tenang dan nyaman ketika dilayani. “Dokter selalu terikat dengan etika, disiplin dan hukum ketika praktek,” papar Prof. Dr. dr. Soenarto Sastrowiyoto, SpTHT (K). Etika, disiplin, dan hukum tersebutlah yang seharusnya dipegang erat seorang dokter yang telah bersumpah di depan Tuhan dan rekan sejawat lainnya.

Penanaman etika dan moralitas seorang dokter tentunya bukan merupakan hal yang dapat dilakukan dengan waktu yang sempit. Sudah seharusnya, pendidikan etika dan moral seorang dokter dimulai dari seorang mahasiswa kedokteran menginjakkan kakinya di Fakultas Kedokteran. Tidak hanya itu, pendidikan ini harus berlanjut di setiap jenjang pendidikan agar mahasiswa kedokteran maupun dokter dapat diingatkan lagi akan kepentingan etika dan moral seorang dokter; terlebih lagi, untuk menerapkan pendidikan itu di kesehariannya sebagai seorang dokter.

A Bridge between “Dreams Big” and “Do No Harm” – “Something the Lord Made” Movie Review

“Something the Lord Made” is a movie which is produced based on the true experiences of Dr. Alfred Blalock, a white American surgeon with his black surgical technician, Vivien Thomas, and his colleague, Dr. Helen Taussig, who was also a pediatric cardiologist. Together, they collaborated in finding the treatment to cure Tetralogy of Fallot, or commonly known as “blue baby syndrome”.

The story starts with Dr. Alfred Blalock hires Vivien as his janitor and he sees Vivien’s potential. Therefore, he gives him chances to develop his ability and promotes him to be a surgical technician along with him as the chief of surgery in America’s prestigious hospital, Johns Hopkins Hospital. They continue on doing medical research which can contribute to the medical development, including when Dr. Taussig asks them to help her in treating one of her patient who suffers from Tetralogy of Fallot. Dr. Blalock and Vivien agree to help Dr. Taussig. They encounter several difficulties which make them think of giving up. However, they choose not to give up for the sake of the patient and their efforts eventually make them succeed in finding the way to treat “blue baby syndrome” patients, pioneer the modern cardiac surgery.

Many people say that medicine is a study of art and science which means that medicine practices arts based on the science. However, I have always believed that humanism is also important in studying and practicing medicine. Good doctors should understand the importance of maintaining the relationships between doctors and their patients. In this way, they will be able to treat patient as a whole, treating not only their physical problems but also their emotional states by always giving care and empathy to them. Arts itself is the expression of humanism. Therefore, I believe that medicine is a combination of arts, science, and humanism.

In my opinion, “Something the Lord Made” goes accordingly to these principles. This movie has left a deep impression and moral value on the importance of being a good doctor and not to mention, a good human being. As a medical student, I was once again reminded that a good doctor was not all about having brilliant knowledge, ideas, and innovations, but also about being a good human being who always respecting other people’s rights, treating others equally, being selfless (promoting altruism), etc.

Dr. Alfred Blalock had inspired me a lot in his braveness and faith towards himself. He was not afraid of breaking the rules which were firmly held by medical doctors at that time, which was “noli tangere – do not touch the heart”, resulting him being mocked around by his colleagues. However, he did not care and he still put efforts to save his patients. Thus, he makes me believe that this braveness and faith do not solely come from his ambition, but also from his devotion to save his patients, making this the main source of him to stay firm and give endless efforts in saving his patients despite negative feedbacks that he received.

Apart from that, Dr. Blalock also respected his patient’s right which was being held by the patient’s parents. He did the informed consent to the family of the patient by explaining the risks and the chances for doing the cardiac surgery in a simple enough way which the parents of the baby would understand. This gave better understanding for the parents towards the surgery. Dr. Blalock also fully understood the parents’ feelings and thus, he was being considerate to the parents and gave the parents of the blue baby time to consider. This is why I think Dr. Blalock had been professional enough to respect and be honest to the parents of the patient.

Nonetheless, I think that Dr. Blalock still lacked in some aspects of professionalism itself due to the fact that he could not control his emotion well under pressure. It can be seen when he was stressed and nervous upon the upcoming cardiac surgery. It was understandable that he contemplated whether he made the right decision to attempt the surgery and he just could not bring himself back to cancel the surgery because of his pride towards the parents of the blue baby. However, he poured out his stress by becoming angry with other people around him; in this case, other health professionals, such as a nurse in the operating room, who was yelled by him because of putting his glasses mistakenly in the wrong place. Consequently, I think that Dr. Blalock was unable to control his feeling really well because he let his mental condition affecting his work.

On the other hand, Vivien’s endless effort and compassion in medical research and development have also stunned me and inspired me a lot. He had always wanted to be a doctor since he was a child and had been saving his money for almost 7 years to go into medical school. Although he did not get to attend one until the end, he still did not abandon that dream and yet pursued it in a different way. I believe staying in Dr. Blalock’s side for years was not easy. He was given a lot of pressures from several parties and treated unequally which made him left his side several times. However, I admire him because he realized that his passion in medicine was bigger than his desire to be known by the public, meaning he was okay for being under Dr. Blalock’s shadow as long as he could continue his research and give contributions to medicine. Fortunately, Vivien’s contribution in medicine was officially appreciated with an honorary doctorate degree in the end of the movie, allowing him to be called as a doctor.

Furthermore, I admire Vivien’s attitude in treating the white doctors well despite of him being discriminated by several white doctors around him. It can be seen from his welcoming attitude towards a doctor in the hospital who wanted to join him in working with the research and his equal treatment to the students after he had been appointed as a doctor. It points out the humanity side of Vivien which replied the inequity that he had received before by treating them kindly as usual, not differentiating the race of people around him. Moreover, he also showed his professionalism for not using his status and remarkable ability as tools to get revenge towards the white people, meaning that he might have forgiven all the mistreats he received before.

Nevertheless, I should admit that Dr. Blalock and Vivien had had a unique and admirable relationship if they were being compared to the other white and black Americans at that time. Racism towards the black people was common at that time, resulting them often being underestimated by the white people in America. However, despite the fact that Vivien was an African – American, he still saw the potential within him and guided him to develop his potential in surgical aspect, even though he was also often being ridiculed by his colleagues for keeping a black person by his side. Meanwhile, Vivien also trusted and respected Dr. Blalock despite his financial difficulties before Dr. Blalock gave him a rise in paycheck. Moreover, he was also suggested to leave Dr. Blalock’s side to search for better jobs numerous times due to the racism occurring around him, resulting him not be able to have his right despite his contributions. Nonetheless, he rejected that idea by stating that he loved what he was doing with Dr. Blalock and believed that Dr. Blalock had also done everything that he could for him.

However, I feel that it is such a waste that Dr. Blalock was unable to give Vivien an appropriate appreciation towards Vivien’s contributions in finding the treatment of Tetralogy of Fallot. In this case, I see the human side of Dr. Blalock. He was overwhelmed with all the praises which he got for succeeding the cardiac surgery and was too greedy to admit that Vivien had also contributed a lot in this surgery. This fact was also supported by the fact that Vivien was not a doctor and he was a black African – American, making him even more invisible in this accomplishment. Nevertheless, it was a comforting moment when Dr. Blalock finally admitted that he regretted all the bad things he had done to Vivien, conveying his sorry to Vivien.

Lastly, I want to emphasize that this movie has great moral values within it. It encourages me not to be afraid of being different than other people and have faith in myself. It can be seen from the principle which Dr. Blalock and Vivien held despite being underestimated by other people. Due to the fact that they kept on trying about something which other people thought was ridiculous and had faith in themselves, they were able to conduct something new and give new understanding about cardiac surgery. We can imagine if they were too afraid to go against the rules and fell into the unsupportive words of other people, we would not have any advanced cardiac surgeries in the world today.

In addition, this movie has successfully encouraged me to dream big. Not to mention, this dream should also be accompanied by endless efforts. Even though the outcome may not be as good as what I expected it to be, I believe it will all be worth it. Everything happens for a reason and thus, everything will be beautiful in its time and all we need to do is just giving our best efforts towards our dreams. To correlate it with the fact that I am being a medical student, this movie encourages me to develop myself to be a better person each day with  contribution to the medical world, whether it is to be a researcher, clinician, or actively contributing in both of it. Moreover, I should not forget to develop humanism, professionalism, and cultural competency so that I am able to be a doctor who is able to treat my patient as a whole and not only treating the disease. In this way, I will be able to maximize the patient’s satisfaction and minimize the potential harms to the patient; thus, making me able to develop the “do no harm” aspect in my future medical practice.